CF 138: That Episode Where Vitalists Tune Out & NSAIDS vs. Cognitive Behavioral Therapy Today we’re going to talk about some research papers that the vitalists in our profession don’t pay attention to and don’t want to hear about because it doesn’t confirm the bias and then we’ll also cover a paper that pits NSAIDS against Cognitive Behavioral Therapy. Cognitive behavioral therapy is a key aspect to treating chronic pain. Very interesting stuff. But first, here’s that sweet sweet bumper music.
OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around. We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. If you haven’t yet I have a few things you should do.
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Do it do it do it. You have found yourself smack dab in the middle of Episode #138 Now if you missed last week’s episode , we were joined by Dr. Aric Frisina-Deyo and discussed his research endeavors and even more importantly, his integration into the FQHC setting, what it’s like and how he did it. Make sure you don’t miss that info. Keep up with the class. While we’re on the topic of being smart, did you know that you can use our website as a resource? Quick and easy, you can go to chiropracticforward.com, click on Episodes, and use the search function to find whatever you want quickly and easily. With over 100 episodes in the tank and an average of 2-3 papers covered per episode, we have somewhere between 250 and 300 papers that can be quickly referenced along with their talking points. Just so you know, all of the research we talk about in each episode is cited in the show notes for each episode if you’re looking to dive in a little deeper.
w/ Dr. Stuart McGill – Clinical Jazz, Treating Kids Like Pros, Thoughts On Posture, and Being A Low Back Pain Ninja
On the personal end of things…..
So far so good. Looking at getting these kids back to school. What a great national debate. Of course, as with anything and everything else, everyone wants to make it a political issue rather than a public health issue. Which is always incredibly disappointing. Listening to a podcast from JAMA, it sure seems it’s not a one size fits all decision. It looks like the answer lies within each different community.
Here’s what I do know for sure regardless of how well kids carry it or how poorly kids spread it, there WILL be some kids get sick and have an extremely hard time with it. Teachers WILL get sick and some WILL die. That’s if they keep the schools open beyond the first week or two. I think it’ll depend on how quickly people start getting sick again. Now, I’m not advocating for or against kids going back to school but I sure don’t want anyone being surprised when it happens. Because it will.
For example, I have a friend that is a teacher. Late 50’s early 60’s. Chronic asthma and just had a heart cath. He does NOT want to go back and I don’t blame him one bit. Some of the larger schools….you simply cannot socially distance. Do you remember what a school hallway looks like during class change? Anyway, these types of teachers, my prayers go out to them. My prayers go out to families like mine that have kids still in school and are worried about their kids and their kids bringing it home to them.
I’ve said it here before; I think that if I get it, I probably do just fine. Yeah, I’m overweight but not so much that I can’t be active and all that. I’m type O+ blood type. I exercise and I don’t have any underlying issues like high blood pressure. I feel like I may get sick as hell but I do well. But the BIG issue is that if I get it, I STILL have to shut my clinic doors for an undetermined number of weeks and that’s just simply not something I’m in a hurry to do. I’m sure you are not either. So, if for no other reason than to keep your doors from closing, it makes sense to continue to protect yourselves and your patients to the highest level possible.
I’m just a few days away right now from taking my son to his first semester of college at Texas Tech in Lubbock, TX. How the hell is college and living in a dorm going to work out for these kiddos? I feel like I can read the future and my crystal ball tells me these kids are going to pass it back and forth like a beer pong ball. Is that good or bad?
Well, on the one hand, it’s good because most all of them will do extremely well with it and that will work toward herd immunity. On the other hand, some will not do so well and some will get sick…..the parents will come to pick them up and take them home to care for them and….well…..you know how it goes from there.
So, I’m concerned. I feel we are going to see what this bug can really do once school starts back up. That’s just my personal opinion. But, we’ve also heard some of the punch this dude packed back in the Spring has gone away and, while people are still dying from it, they are not dying in the numbers they were back in the Spring. Don’t get me wrong here, I’m not cowering in fear in the corner afraid to touch people in my practice.
Outside of the first two weeks, we’ve been open 100%. I’m seeing about 140 per week right now. Shaking hands…..maybe even a little hug here and there. I just wear a mask and wash my hands a lot. We have the UV air scrubbers. We check temp and symptoms when they come in the door. We clean like crazy. But nothing I would consider overboard and…..So far so good.
So….what do we do? We sit, wait, and watch. Just like we have been doing since February. In a way, I almost envy the deniers, the non-sciencers. They are just going through this oblivious with little to no sense of danger and non-ending mockery of the sciencers of the world. They say ignorance is bliss and you can see it on display on social media every day all day.
Unless you’re like me of course. I have the non-sciencers snoozed for 30 days so I don’t have to see the foolishness and can still enjoy myself. I’m no expert in virology. I’m no epidemiologist. The difference between me and the non-sciencers is that I’ll freely admit that and will go actively looking for the answers in the research, from the experts, and through JAMA rather than ignoring science, ignoring experts, and listening to foolishness and propagating idiocy.
But…..that’s just me.
Item #1 Let’s get to this first one called “Nonsteroidal Anti-inflammatory Drugs vs Cognitive Behavioral Therapy for Arthritis Pain; A Randomized Withdrawal Trial” by Fraenkel, et. al. (Fraenkel L 2020) and published in JAMA on July 20, 2020. Hot tater, pitch it around, hot tater… Why They Did It Is replacing meloxicam with placebo about the same as continued meloxicam, and is engaging in a telephone-based cognitive behavioral therapy program about the same as continuing meloxicam for patients with knee osteoarthritis? How They Did It
- 364 patients that took NSAIDs for knee osteoarthritis most days of the week for at least 3 months
- The subjects stopped taking the NSAID and took 15 mg per day of meloxicam
- Those who remained eligible were randomized in a 1:1 ratio to receive meloxicam or placebo for 4 weeks
- Participants receiving meloxicam then continued this medication for 10 weeks, while those receiving placebo participated in a 10-week cognitive behavioral therapy program
What They Found
- A total of 180 were randomized to get the placebo followed by CBT
- 184 were getting the meloxicam
- The estimated difference in the WOMAC pain score between the two groups after 4 weeks was 1.4
- After 14 weeks, the difference was .8
- There was no statistically significant difference in the pain or in disability
Wrap It Up Among patients with knee osteoarthritis, placebo and cognitive behavioral therapy (after placebo) are inferior to meloxicam. However, the WOMAC pain score differences between the 2 groups were small, and there were no statistically significant differences in participants’ global impression of change or function after 14 weeks.
I have been searching for a cognitive behavioral therapist locally for some time now and have yet to identify one in my market. The only cognitive behavioral therapist I have found is at the VA so the public doesn’t have access to them. I’m still searching. It’ll happen eventually because chronic pain isn’t going anywhere and cognitive behavioral is going to get more and more important as they continue to learn more and more about the ability of cognitive behavioral therapy to help these folks. Before we get to the next paper, I want to tell you a little about this new tool on the market called Drop Release. I love new toys!
If you’re into soft tissue work, then it’s your new best friend. Heck if you’re just into getting more range of motion in your patients, then it’s your new best friend. Drop Release uses fast stretch to stimulate the Golgi Tendon Organ reflex. Which causes instant and dramatic muscle relaxation and can restore full ROM to restricted joints like shoulders and hips in seconds. Picture a T bar with a built-in drop piece.
This greatly reduces time needed for soft tissue treatment, leaving more time for other treatments per visit, or more patients per day. Drop Release is like nothing else out there, and you almost gotta see it to understand, so check out the videos on the website.
It’s inventor, Dr. Chris Howson, from the great state of North Dakota, is a listener and friend. He offered our listeners a great discount on his product. When you order, if you put in the code ‘HOTSTUFF’ all one word….as in hot stuff….coming up!! If you enter HOTSTUFF in the coupon code area, Dr. Howson will give you $50 off of your purchase. Go check Drop Release at droprelease.com and tell Dr. Howson I sent you.
Item #2 This one is called “The accreditation role of Councils on Chiropractic Education as part of the profession’s journey from craft to allied health profession: a commentary” by Innes et. al. (Innes S 2020) published in Biomed Central on July 22, 2020. Whew….whew the hotness. Cool it down here.
This is an article so we’ll hit the high spots here:
- Chiropractors see themselves as well positioned to provide safe, effective and economical care for the on-going financial burden that spinal pain imposes. However, in many places of the world, the chiropractic profession continues to find itself struggling to gain acceptance as a mainstream allied health care provider.
- They say there is a need for scrutiny of international chiropractic educational accreditation standards, which are the responsibility of Councils on Chiropractic Education (CCEs)
- They found that there is sufficient evidence to identify areas of concern that could be addressed, at least in part, by improvements to CCEs’ educational standards and processes.
- Areas included a lack of definitions for key terms such as, ‘chiropractic’, ‘diagnosis’, and ‘competency’, without which there can be no common understanding at a detailed level to inform graduate competencies and standards for a matching scope of practice.
- They go on to say there is some evidence to suggest that in some cases this level of detail is avoided in order to enable a “big tent” approach that allows for a diversity of approaches to clinical care to co-exist. This combined with the held view that chiropractic is “unique”, highly valued, and best understood by other chiropractors, explains how students and practitioners can cling to ‘traditional’ thinking. This has implications for public safety and patient quality of care.
- They say that despite the global implications of low back pain, the low utilization of chiropractic has remained unchanged over the past 35 years or so. Mostly because we are not gaining mainstream acceptance to the point of being on equal footing with others. Why the hell could that be ya think?
They wrap up the conclusion as follows, “If chiropractic care is to gain mainstream acceptance worldwide then it needs to adopt, through revitalized CCE accreditation standards and processes, those of other allied healthcare professions and wholeheartedly embrace science, evidence-based practice and patient-centered care.”
Ya can’t say it any clearer than this folks. This is the core of the issue. If you are a regular listener, then you know a couple of weeks ago, we covered a bit older paper about what chiropractic can learn from podiatry. This…..this is it just in different words. Non-sciencers act like WE’RE the ones destroying the profession of chiropractic.
Where I stand, and the way I see it, the evidence-based, patient-centered practitioners…..the sciencers….are the ones desperately trying to save the profession, its reputation, and bring it into the year 2020 instead of the early 1900s. This is a loooonnnggg article. I didn’t read all of it. I didn’t have the time but, my conclusion for you is this; we have to learn, adapt, upgrade, and advance. You just have to people. Dammit.
w/ Dr. James Lehman (Pt. 1) – National Scope, Chronic vs. High Impact Chronic, Coordinated Care/Medicaid, DACO to DIANM
In yet one more effort to make the vitalists hate me, this new one is called “The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature” by Corso, et. al. (Corso M 2020) and published in Biomed Central Chiropractic and Manual Therapies on July 9, 2020, sizzlin’ sausage and saurkraut surprise…. Why They Did It To determine the diagnostic and therapeutic utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine and to investigate whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. How They Did It
- They searched MEDLINE, CINAHL, and Index to Chiropractic Literature from the days of Adam and Eve to November 25, 2019.
- They used rapid review methodology recommended by the World Health Organization
- 959 citations, 176 screened, and 23 critically appraised.
What They Found
Nine low risk of bias studies investigated the validity and reliability of routine or repeat radiographs. These studies provide no evidence of clinical utility.
Wrap It Up
“We found no evidence that the use of routine or repeat radiographs to assess the function or structure of the spine, in the absence of red flags, improves clinical outcomes and benefits patients. Given the inherent risks of ionizing radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine.” If you’re just now hearing this, welcome to the show. We’ve been saying this for a while now. ACA has been saying this through Choosing Wisely since about 2016 or so.
I cannot fault you for wanting x-rays on the first visit. Some are just uncomfortable otherwise. Who am I to tell you to not shoot those? However, the repeated and updated x-rays…..nope. No sir. No ma’am. Cut it out.
If you’ve been listening, there is even some idea or evidence that repeated x-rays like this may potentially be an impetus for neurodegenerative disease. So…..if you bought that x-ray machine thinking it was going to be a cash register ringing up the dollars for you, you’re going to have to stop, take a step back, re-evaluate your practices, and use it like most other healthcare practitioners use imaging. Sparingly and only when necessary. Alright, that’s it. Y’all be safe. I hope y’all enjoyed the cognitive behavioral discussion.
Good stuff. Keep changing the world and our profession from your little corner of the world. Continue taking care of yourselves and taking care of your neighbors. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.
Store Remember the evidence-informed brochures and posters at chiropracticforward.com.
The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient.
And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!
Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!
Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms. We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference.
Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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About the Author & Host Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
Bibliography Corso M, C. C., Mior S, TKumar V, Smith A, Cote P, (2020). “The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature.” BMC Chiro Man Ther 28(33).
Fraenkel L, B. E., Suter L, (2020). “Nonsteroidal Anti-inflammatory Drugs vs Cognitive Behavioral Therapy for Arthritis Pain A Randomized Withdrawal Trial.” JAMA.
Innes S, L.-Y. C., Walker B, (2020). “The accreditation role of Councils on Chiropractic Education as part of the profession’s journey from craft to allied health profession: a commentary.” BMC Chiro Man Ther 28(40).